Despite being the most widely researched procedures in surgical history, coronary arterial-bypass grafting (CABG) and balloon angioplasty (PTCA) do not increase a stable angina patient's chance of survival any more than realistic lifestyle modification and appropriate medication to control symptoms.
Since 1991, the American Heart Association has consistently stated that heart surgery should only be considered if the patient is unstable and has poor left ventricular function due to severe three-vessel disease or other significantly life-threatening factors.
The UK has no such guidelines, leaving it to the individual surgeon to decide whether or not to operate.
Based on US research, up to 80 per cent of the 25,000 CABG operations undertaken last year in Britain were not necessary and were in themselves potentially life-threatening to patients.
The decision to operate is often based on a negative result on stress (treadmill) testing. Patients with changes in their electrocardiograms (ECGs) over less than six minutes are usually referred for a coronary angiogram (injecting contrast material into the blood vessels to make them show up on an X-ray). This procedure itself causes death in 0.2 per cent of cases and can also trigger a heart attack, stroke or severe blood loss. Yet, most patients are not made aware of these risks.
Angiography should only be used to establish the location and severity of a block, and the efficiency of heart function. But the decision to operate should not be based solely on the degree of blockage, but should consider heart function, lack of symptoms or amount of blood flow through the heart.
An 80-year-old patient may have an 80-per-cent block without symptoms whereas a 50-year-old may develop angina pain with as little as a 50-per-cent block. Even a 100-per-cent block does not necessarily cause a heart attack if the patient has effective blood flow through smaller vessels adjacent to the affected artery. Such a 'natural bypass' develops over time in patients who undertake regular exercise.
Death rates due to CABG in the worst-performing NHS hospitals show that the operation reduces, rather than extends, the patient's survival. A survey in The Sunday Times showed that death rates varied from 1.4 to 7.4 per cent (average: 3 per cent) within 30 days of the operation.
Death rates from coronary heart disease (CHD) vary according to age, severity and preventative measures: the older the patient, the less CHD risk factors are controlled. Yet, the 7.3 million high-risk senior citizens in Britain are failing to take control of their lives through lifestyle changes that could improve the quality (and quantity) of their lives.
The reduction of CHD in the over-75s is not an NHS target. The NHS spends only 1 per cent of its lb1.6 million CHD budget on prevention and education despite the lb10 billion cost to the nation in loss of productivity and sickness-benefit payments. The millions invested in more operating theatres, staff and intensive-care beds would be better spent on screening those at risk as well as on prevention, education and cardiac rehabilitation.
We are failing to get across the message of the health hazards of smoking, and have yet to influence the nation in terms of exercise, obesity, a healthy diet and a sensible lifestyle.
The Bypass Angioplasty Revascularisation (BARI) study (Circulation, 1997; 86: 456-61) purported to show that survival rates were greater from CABG vs medication, but a recent, unheralded analysis of the study clearly demonstrated that any benefit was solely attributable to lifestyle changes. The analysis concluded that the combination of more rehabilitation support and a greater motivation to stay well directly influenced more patients to reassess their lifestyle.
The analysis also showed that stopping smoking, exercise, weight loss, a balanced, healthier diet, and taking medications to control high blood pressure and high cholesterol resulted in patients living longer and with a better quality of life. It was not the result of the CABG operation.
The recent Randomised Intervention Trial of Unstable Angina (RITA) study (Lancet, 2002; 360: 743-51) focused on the 20 per cent of the two million heart patients who become unstable. Yet, the report made no mention of whether heart function or lifestyle changes were monitored or recorded - a strange omission, given the positive impact of lifestyle changes in such patients.
Dr Dean Ornish's Lifestyle Heart Trial proved that implementing fundamental lifestyle changes and taking therapeutic vitamins together with medication helped CHD patients reduce symptoms in 91 per cent of cases, and reduced heart attacks by 75 per cent (Circulation, 1989; 80: II-57).
Chelation therapy may also benefit patients in conjunction with oral supplementation, appropriate medicine and lifestyle changes. A meta-analysis of clinical studies of chelation involving over 23,000 patients showed significant, measurable improvements in over 80 per cent of patients (J Adv Med, 1993; 6: 141-61).
It's never too late to start reassessing the way you live. Losing excess weight is not life-threatening, and smoking is inextricably linked with heart disease.
Changing your way of life is surely better than sacrificing it by going under the knife for an operation that is clearly questionable, highly dangerous and largely unnecessary.
John Buckley is director of The Arterial Disease Clinic (Johnbuckley@chelationuk. com).